The concept of "Health For All", envisages the attainment of a level of health that permits all the people of the world to lead a socially and economically productive life. This goal has been guiding health strategies all over the world for the past two decades. However, in the present day heterogeneous world, with wide disparities in health and social conditions existing between countries and regions, the achievements in health are also dissimilar. Now at the threshold of the third millennium, the world community has realized that despite commendable progress recorded in many places, HFA has to be set in a new perspective. Therefore, it is forging ahead with renewed optimism and energy. This feeling of hope was duly reflected in the WHO’s World Health Report of 1998.

The Global perspective
The new target set to achieve HFA is by the end of the second decade of the 21st century. Among the new strategies adopted for the purpose, ‘Health Promotion’ occupies the pride of place because of its potential to bring about a substantive shift in the concept and practice of health by the individual, community and the society at large. Health Promotion aims at behavioural changes that lead to improved health status of the population. Health promotion, to be effective, needs to be duly backed up by proper health policies, sufficient resources and need-based health care delivery systems.

The unaddressed challenges of the present century will be carried over to the next one, with few additions of its on. Whether newer technologies and advancements will be able to meet these unmet needs is a futuristic question. But reaching the benefits of these developments to larger populations, who need them most, will be a major challenge.

Future challenges
The demands will increase as nearly 80 million people are added every year to the present world population of 5.8 billion. Demographic problems, communicable and non-communicable and lifestyle-related diseases, economic tardiness, environmental degradation, especially in the poorer countries etc., are probable challenges for the next century.
HIV/AIDS will continue its devastating spell in the 21st century. According to WHO, 590000 children aged below 15 became infected with HIV in 1997. This trend might reverse some of the major gains in child health achieved in the last 50 years. 15 million adults aged 20-64, including 585000 young pregnant women, are dying every year, most of which from premature and preventable causes. Violence, delinquency, drugs, alcohol, motor accidents and sexually transmitted diseases etc. are likely to continue to threaten world health. Leading causes of death from infectious diseases were acute lower respiratory infections 3.7 million, tuberculosis 2.9 million, diarrhoea 2.5 million, HIV/AIDS 2.3 million and malaria 1.5 - 2.7 million. Most deaths from circulatory diseases were coronary heart disease 7.2 million, cerebrovascular disease 4.6 million other heart diseases 3 million. These health problems will pose similar or greater dangers to world health in the coming century.

The Ottawa Charter
The first International Conference on Health Promotion in Ottawa, Canada in 1986 drew up a Charter which recognized health and its maintenance as a major social investment and challenge. The document defined Health Promotion as the process of enabling people to increase control over the determinants of health and thereby improve their health. It stressed the need to move towards a ‘New Public Health Approach’ by focusing on supporting health, improving the preconditions for health and promoting healthy behaviour. The prerequisites for health were listed as: peace, shelter, education; food, income, stable eco-system, sustainable resources, social justice and equity. Many countries set health goals and targets, not just on individuals and their behaviour, but also on the environment, ‘where people live, work and play’.
As per WHO the ‘settings for health’ approach to health promotion has led to projects focused on healthy cities, healthy villages, healthy islands, health-promoting hospitals, healthy schools, healthy marketplaces, healthy companies, healthy and safe workplaces, and even healthy prisons.

The Jakarta Declaration
The Jakarta Declaration was adopted at the Fourth International Conference on Health Promotion "New Players for a New Era" in July 1997. It called on WHO to take the lead in building a global health promotion alliance and to engage governments, non-governmental organisations, private sector, international agencies etc. in advancing the priorities for action in health promotion. This Declaration was a significant step towards a new orientation to the worldwide health promotion activities emphasizing on a practical approach to achieve greater equity in health.

The 51st World Health Assembly
The 51st World Health Assembly was held in Geneva from 11 - 16 May, 1998 where delegates from 191 Member States assembled and adopted the World Health Declaration stating that "changes in the world health situation require that we give effect to the `Health for All Policy for the 21st century’ through relevant regional and national policies and strategies". The delegates as a community of nations, decided to act together to meet common threats and to promote universal well-being.

The National perspective
Developing countries are going to face tremendous challenges in health promotion in the next century due to lack of health sector funding. Old and emerging diseases fueled by galloping populations will stretch their resources. Poor management of the health services sector will further aggravate the situation. The public health care system which is the mainstay for the masses has wilted under the pressure. Burgeoning urbanization and concentration of medical facilities in cities have also added fuel to the fire, creating unhealthy urban slums and over-crowding - a sad reality to be reckoned with in health planning.

Health promotion at an individual level should influence his/her knowledge, lifestyle and behaviour. At the community level it should encourage actions that supports health. It may call for a multisectoral approach aimed at removing social inequities, adopting sustainable consumption patters which help improve health conditions. At the national level health promotion should be directed towards development programmes which are human-centred and eco-friendly.

As far as decisions on health and related matters are concerned, people must have meaningful participation, which will result in better health conditions for the people. The private sector in India, as elsewhere, occupies a predominant role in health care delivery by covering about 70-75% of medical service and still growing. But the unhindered growth of this sector with emphasis on high technology and profit may not always be a boost to health promotion. But there is a third sector, the voluntary sector, which is known for innovative approaches in health promotion.

The NGO perspective
India has a rich tradition of voluntary action in several areas including health. The health promoters among the people were the traditional healers who were part and parcel of the community they belonged to. Their medical care methods were ethnically acceptable and were based on locally available herbs and plants. The introduction of the modern allopathic system of medicine marked the decline of the age-old Indian systems. The western concept of health care was institutionalised i.e. hospital-based unlike the traditional Indian systems.
Questions about the efficacy of hospital-based curative health care began to be raised in the mid-sixties. Then there was a trend towards a more decentralised, community-oriented health care system which was closer to the people. Several initiates emphasizing preventive aspects of health care came up because of pioneering efforts by people of vision. They called this new approach ‘Community Health’. But many of these programmes were mostly western medicine oriented. Lot of local health practices were absorbed, but still the traditional systems did not get proper support and encouragement.
Organization like VHAI, CHAI and numerous other institutions propagated the concept of community health and primary health care with lot of enthusiasm and missionary zeal in the seventies. As a result several initiatives in alternative health care, under dynamic and charismatic leaders, were initiated in India, such as Jamkhed, Deenabandhu, Pachod, Oddenchatram, Padhar and Gandhigram, Seva Ashram and Anandwan etc. to name a few. Their contributions towards bringing about a different understanding of health care have been significant which proved that alternative approaches in health care can work in certain areas, provided a particular social environment can be created. This change in perception took place, as it became increasingly clear that information dissemination alone did not necessarily result in attitudinal or behavioural changes in communities.
Currently about 7000 agencies are estimated to be involved in health promotion activities throughout the country. Their activities also include development aspects like income generation, water harvesting, sanitation, nutrition etc. These agencies, mostly with very modest resources, try to work out need-based alternative development models which are culturally acceptable, cost-effective and simple. An attempt to demystify medical care has been tried out by many organisations, by developing a health care delivery system using local health workers.
But the major problem faced by these agencies have been the pure vastness of the problems vis-a-vis their own limitations. They could never replace the mammoth government infrastructure, which in many situations were redundant, lethargic and inappropriate because of inherent contradictions and complications. On the other hand, the NGOs have concretely proved that significant changes in health care were possible with strategies and approaches based on awareness building, conscientisation and empowerment. In the overall health care delivery system of the country, voluntary agencies have played a major role. Because of their closeness to the people and other advantages, they are best suited for community organization and health promotion. Instead of coming in conflict with the state, medical establishments and medical industries, they work as catalysts for change for optimum impact. Despite several limitations, the voluntary agencies have made significant contributions to health promotion in the post-independent era in India.

The Grassroots perspective
Health is not the concern of the establishment alone, but of every individual, families and communities; though few would know what it really means. So promoting health among individuals and communities is a process in which many players are involved, such as health policy planners, doctors, nurses, auxiliary nurses, midwives and lastly the health workers. Health workers are generally members of the community they serve. They are the first reference points in a rural situation in health matters. Their responsibilities are varied, ranging from providing simple medical care to reporting to higher authorities about health problems of the people. Another very important job handled by health workers is to promote health through educating the community on the basics of good health. To become effective health promoters, these workers need training in health promotion. An informed health worker helps eradication and control of diseases like leprosy, malaria, TB, water-borne disease etc. Immunizations and family planning are also part of their responsibility.
There are several NGOs like VHAI, Chetna and others who are involved in networking and empowering of health workers. These agencies produce health education materials for health workers. VHAI’s "Hamari Chitti Apke Naam" for health workers in 19 languages running into more than 100 thousand copies is a case in point. There are periodic `Health Workers’ Conventions’ and exchange visits with the idea of building up the capacities of health workers in their health promotion activities. The importance of health workers in health promotion can never be underestimated.

A Case for the unheard and unsung
Like in the case of medical care concentrated in urban areas, voluntary agencies have also got centred around cities and towns. There are areas of extreme needs, where neither voluntary or government sector has reached. These are the so called ‘areas of darkness’. For instance there are limited voluntary actions in some of the least progressed states collectively called the ‘BIMARU’ states (Bihar, Madhya Pradesh, Rajasthan and Uttar Pradesh), as against better-off states like Kerala or Maharashtra. The Voluntary Health Association in its ‘State of India’s Health Report’ had identified several such areas. This promoted the agency to take up the challenge of promoting health in some of these difficult areas.
Under this backdrop, the members of the ‘Independent Commission on Health in India’ in its recently released report has suggested to the Government to set up a National Coordination Committee consisting of members from voluntary agencies and government with wide-ranging powers to plan and monitor the management of health in the country.
A people-oriented Public Health Policy is the corner-stone for all welfare programmes and their implementation. These policies are influenced by the actions taken on issues like housing, environment, economic conditions and political settings, which are outside the health sector. Therefore, a comprehensive health promotion policy is essential for the proper development of health in both developing and developed countries.
On the prospects and problems of future, Dr. Gro Harlem Bruntdland, Director-General of WHO says "Societies can be changed and that poverty can be fought. The challenges go to all of us. The transition from one century to another sees changes which will be faster and more dramatic from an economic, social and health perspective. The burden of disease is the burden of unfulfilled human development".

KHOJ

KHOJ is an innovative effort introduced in the country by the Voluntary Health Association of India (VHA) in 1994, to support, develop and sustain health promotion in some of the most difficult and undeveloped regions (areas of darkness). The health scenario in these backward regions is bleak with rampant child malnutrition, frequent epidemics of water-borne disease, etc. A holistic, non-exploitative and sustainable developmental process is absent in these regions.
KHOJ means ‘search’ - a search for solutions. It is an initiative aimed at effecting comprehensive changes in the lives of the target population, through health, social and economic upliftment of the community, leading to long-term improvement in health. Presently there are 17 KHOJ projects being implemented in ten states of India. They are also referred to as ‘Community Health Packages’. Need-based planning, training of personnel involved in the project, regular visits by technical people from VHAI, periodic evaluations and revisions of strategies, according to changing needs, are the hallmarks of KHOJ projects. These projects are supported by EZE, Germany.
Standardized reporting and reviewing systems are in place. Most of the KHOJ projects have a well-equipped small (2-4 bedded) hospital/health centre. Regular out-patient services and free/subsidized medical treatment are provided in these centres. These services are augmented by mobile clinics, which reach out to people who have difficulty in visiting the health centres. Medical kits are provided to each village health worker and safe delivery kits to all trained dais of the KHOJ projects. For sustainability, income-general programmes have become an integral part of these projects.
VHAI wants to see this process grow in strength and effectiveness in the coming years, so that a chain of model projects can be developed in some of the most inaccessible pockets. KHOJ experiments has given VHAI a great deal of insight into the needs of the people in remote areas.

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